电子病历在学生临床实习中的作用及出现的问题探讨  

Role and Problems of Electronic Case Records in Students' Clinical Practice

作　　者：郑新瑞[1] 王宏斌[2] 张珊红[2] 路荣[3] 王冠英[2] 

机构地区：[1]第四军医大学研究生管理大队,陕西西安710032 [2]第四军医大学西京医院质量管理科,陕西西安710032 [3]第四军医大学西京医院数字化中心,陕西西安710032

出　　处：《西北医学教育》2012年第4期834-836,共3页Northwest Medical Education

摘　　要：电子病历为医院信息化发展的必然产物,大大的提高了临床工作效率,它在为临床实习提供快捷便利的学习和应用途径的同时,也给临床实习带来了诸多负面影响。如模板选择使用不当,导致大量病历内容雷同,逻辑思维和综合判断受限,独立分析问题的能力减弱等。在医院信息化的背景下,强化病历质量意识教育,重视病历书写培训考核,规范三级查房,通过医疗实践增强临床思维能力,对提高实习及教学质量有很大帮助。Electronic medical record, as an inevitable outcome of hospital informatization, has greatly improved the efficiency of clinical work. It provides convenient study and application as well as nega- tive effect in clinica! practice. Such as improper use and selection of template, duplicate contents of medical record, Limit of logical thinking and comprehensive judgment, diminished capacity of inde- pendent analysis. By strengthening medical record quality awareness education; attaching importance to medical record writing training; standardizing three-level doctor ward round; enhancing clinical thinking ability through medical practice, it will be a great help to improve the quality of clinical teaching and practice in the background hospital informatization.

关 键 词：电子病历 临床实习 医院信息化 

分 类 号：G642.44[文化科学—高等教育学]